Patient Demographic Form Page 3
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Patient Name: ____________________________
FAMILY HISTORY: □ None of the below
Condition
Family Member Affected (Indicate Maternal/Paternal)
Melanoma
Basal/Squamous Cell Carcinoma
Asthma
Allergies
Psoriasis
Alopecia
Arthritis
Diabetes
SOCIAL HISTORY:
□Unemployed
□Retired
□Homemaker
□Student
□Child
Occupation:_____________________
Tobacco Use: □Never
□Former
□Unknown
□Cigarettes/day
Alcohol Use: □Never
□Monthly or Less
□2-4/Month
□2-3/week
□4+/week
Alcohol or drug problems/addictions: □ No □Yes; Describe: ____________________________________________
Sunscreen: □None
□Daily
□Occasionally
Tanning Bed: □No use
□Current
□Previous
□Pregnant
□Breastfeeding
□Planning to become pregnant
□Birth Control
□None
Females:
CURRENT MEDICATIONS: **Including over the counter products + vitamins**. □None □See attached
____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
□None
ALLERGIES TO MEDICATIONS:
Medication
Reaction
□None
PREVIOUS SKIN CANCER HISTORY IN DETAIL:
Date
Type of skin cancer and treatment
REASON for today’s visit
Our doctors will try to address all of your concerns, but due to time restraints, the consultation may be continued at another visit.
1.____________________________________________________________________________________________
2.____________________________________________________________________________________________
Are you interested in hearing about any of our cosmetic services and/or products?
□ Yes
□No
Patient Signature______________________________________________________Date_____________MD______
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Parent category: Medical